Oesophageal and tracheal perforation in thyroid B-cell lymphoma

We report an unusual case of spontaneous oesophageal and tracheal perforation secondary to thyroid B-cell lymphoma in a previously healthy 76-year-old woman. Findings on chest radiography, CT and oesophagram are correlated to endoscopy, surgery and pathology. Such perforation is a rare and serious complication that should be specifically considered when a patient with a neck neoplasm develops acute respiratory or gastrointestinal symptoms.

Successful treatment of Nocardia nova bacteremia and multilobar pneumonia with clarithromycin in a heart transplant patient

Nocardia is an opportunistic pathogen in solid organ transplantation for which long-term sulfonamide therapy is considered the treatment of choice. We report a patient 7 months status post-orthotopic heart transplantation with Nocardia nova bacteremia and pneumonia. Initial treatment consisted of intravenous trimethoprim-sulfamethoxazole, which cleared blood cultures, but the patient subsequently went into renal failure and required alternative therapy. This report describes the first case of N nova bacteremia after orthotopic heart transplantation successfully treated with clarithromycin. All therapy should be guided by antibiotic sensitivity, and combination therapy should be considered in acutely ill patients and cases where in vitro synergy has been documented. This case suggests that clarithromycin can be an alternative treatment in cases of sulfonamide resistance, intolerance, or allergy.

Hepatitis E virus infection among animals in northern India: an unlikely source of human disease

Hepatitis E virus (HEV) is a major cause of acute hepatitis in many developing countries. Based on data from nonendemic regions, an animal reservoir of HEV has been proposed; however, data from HEV-endemic regions are limited. We tested sera from 200 pigs, 98 chickens, 86 goats, 58 sheep and 30 buffaloes for anti-HEV IgG using two different enzyme immunoassays. Specificity of the detected antibodies was confirmed using inhibition assays. Stool specimens from 210 pigs, 94 piglets and 37 sheep were tested for HEV-RNA using nested amplification methods; the polymerase chain reaction products were sequenced and compared with known human and swine HEV sequences. Of the 200 swine sera, 193 and 195, respectively, tested positive in the two assays. All goat sera showed anti-HEV reactivity in both the assays. Inhibition studies confirmed the HEV specificity of antibodies detected in swine and goat sera using both the assays. Sera from sheep, buffalo and chickens also showed high rates of apparent reactivity, but inhibition studies were unable to confirm the specificity of reactions in these species. One faecal specimen showed amplification using Indian swine HEV-specific primers. The genomic sequence of the amplicon from this isolate had only 76-79% nucleotide and 93% amino acid homology with human HEV isolates reported from India and other parts of the world, and most closely resembled swine HEV isolates from other parts of India. Infection with HEV or a related agent is widespread among animals in northern India. However, the swine HEV in India differs genetically from human HEV isolates, indicating that pigs may not play an important role in the spread of human hepatitis E in endemic regions.

T-cell epitope mapping of ORF2 and ORF3 proteins of human hepatitis E virus

Little data are available on cellular immune responses during infection with hepatitis E virus (HEV). We therefore mapped CD4 T-cell epitopes in open reading frame (ORF)2 and ORF3 proteins of HEV using lymphocyte proliferation assays and overlapping peptide libraries. Proliferation of peripheral blood mononuclear cells from 40 patients with acute hepatitis E and 21 healthy controls with recombinant HEV ORF2 protein or pools of overlapping HEV ORF2/ORF3 peptides was measured. HLA-DQB1 and HLA-DRB1 alleles were also determined. Mononuclear cells from patients with hepatitis E more often showed significant proliferation on stimulation with recombinant ORF2 protein than controls (32/40 vs 7/21), and had higher median (range) stimulation indices [2.6 (0.9-15.2) vs 1.3 (0.6-12.9)]. Peptide pools corresponding to amino acids 73-156, 289-372, 361-444 and 505-588 of HEV ORF2 protein were associated with significant proliferation. Individual peptides in these pools did not show a clear pattern of stimulation. HEV ORF3 peptide pools did not induce proliferative responses. Lymphocyte proliferation in response to the peptide pool corresponding to amino acids 289-372 of HEV ORF2 protein was associated with presence of HLA-DRB1 allele 010X. These data on mapping of T-cell epitopes in HEV proteins may prove useful for designing HEV vaccines and for studying the immunopathogenesis of hepatitis E.

Comparison of generalized autocalibrating partially parallel acquisitions and modified sensitivity encoding for diffusion tensor imaging

BACKGROUND AND PURPOSE

Diffusion tensor magnetic resonance imaging (DTI) of the brain is usually acquired with single-shot echo-planar imaging, which is associated with localized signal loss, geometric distortions, and blurring. Parallel imaging can lessen these artifacts by shortening the length of the echo-train acquisition. The self-calibrating parallel acquisition techniques, image domain-based modified sensitivity encoding (mSENSE) and k-space-based generalized autocalibrating partially parallel acquisitions (GRAPPA), were evaluated with DTI of the brain in 5 healthy subjects.

METHODS

GRAPPA and mSENSE with higher acceleration factors (R) up to 4 were compared with conventional DTI (with and without phase partial Fourier, another method of reducing the echo-train length) on a 1.5T Sonata scanner (Siemens, Erlangen, Germany). The resulting images and diffusion maps were evaluated qualitatively and quantitatively. Qualitative analysis was performed by 3 reviewers blinded to the technique using image sharpness and the level of artifacts as characteristics for scoring each set of images. Quantitative comparisons encompassed measuring signal-to-noise ratio, Trace/3 apparent diffusion coefficient (ADC), and fractional anisotropy (FA) in 6 white-matter (WM) and gray-matter (GM) regions.

RESULTS

Reviewers scored the GRAPPA and mSENSE R = 2 images better than images acquired with conventional techniques. FA contrast was improved at the GM/WM junction in peripheral brain areas. Trace/3 ADC and FA measurements were consistent for all methods. However, R = 3,4 images suffered from reconstruction-related artifacts.

CONCLUSIONS

GRAPPA and mSENSE (R = 2) minimized the susceptibility and off-resonance effects associated with conventional DTI methods, yielding high-quality images and reproducible quantitative diffusion measurements.

A potential role for interleukin-18 in inhibition of the development of Cryptosporidium parvum

Accumulating evidence suggests that intestinal epithelial cells (IECs) constitutively express the immunoregulatory cytokine interleukin (IL)-18. IECs also serve as the host cell for the intracellular parasitic protozoan Cryptosporidium parvum. In the present study, C. parvum infection of a human enterocyte cell-line HCT-8 resulted in increased expression of IL-18 mRNA as measured by quantitative reverse transcription-polymerase chain reaction (RT-PCR). IL-18 protein was detected in control uninfected cells and following infection there was increased expression as measured by enzyme-linked immunosorbent assay (ELISA). Gene expression revealed the presence of the IL-18 receptor subunits not only in cell-lines but also in freshly isolated IECs, suggesting that IL-18-mediated signalling events may contribute to epithelial host defence during infection. Recombinant IL-18 inhibited intracellular development of the parasite in HCT-8 and HT-29 cells. Increased expression of bactericidal antibiotic peptides LL-37 and alpha-defensin 2 by IL-18 in HCT-8 and HT-29 cells may represent one mode of action by which this pluripotent cytokine aids in limiting the development of intracellular pathogens such as C. parvum in the gastrointestinal tract.

Incarcerated inguinal hernia presenting as spontaneous scrotal fecal fistula

We report a case of neglected, strangulated, inguinal hernia in a middle-aged male, which presented as a scrotal fecal fistula. This is the first such case reported in an adult. The patient was treated by resection and anastamosis of the ileum, local debridement of the scrotum and Shouldice repair for the inguinal defect.

Bone mass in Indian children--relationships to maternal nutritional status and diet during pregnancy: the Pune Maternal Nutrition Study

CONTEXT/OBJECTIVE

Bone mass is influenced by genetic and environmental factors. Recent studies have highlighted associations between maternal nutritional status during pregnancy and bone mass in the offspring. We hypothesized that maternal calcium intakes and circulating micronutrients during pregnancy are related to bone mass in Indian children. DESIGN/SETTING/PARTICIPANTS/MAIN OUTCOME MEASURES: Nutritional status was measured at 18 and 28 wk gestation in 797 pregnant rural Indian women. Measurements included anthropometry, dietary intakes (24-h recall and food frequency questionnaire), physical workload (questionnaire), and circulating micronutrients (red cell folate and plasma ferritin, vitamin B12, and vitamin C). Six years postnatally, total body and total spine bone mineral content and bone mineral density (BMD) were measured using dual-energy x-ray absorptiometry (DXA) in the children (n = 698 of 762 live births) and both parents.

RESULTS

Both parents' DXA measurements were positively correlated with the equivalent measurements in the children (P < 0.001 for all). The strength of these correlations was similar for fathers and mothers. Children of mothers who had a higher frequency of intake of calcium-rich foods during pregnancy (milk, milk products, pulses, non-vegetarian foods, green leafy vegetables, fruit) had higher total and spine bone mineral content and BMD, and children of mothers with higher folate status at 28 wk gestation had higher total and spine BMD, independent of parental size and DXA measurements.

CONCLUSIONS

Modifiable maternal nutritional factors may influence bone health in the offspring. Fathers play a role in determining their child's bone mass, possibly through genetic mechanisms or through shared environment.

Hydrogen peroxide tooth-whitening (bleaching) products: review of adverse effects and safety issues

Hydrogen peroxide in the form of carbamide peroxide is widely used for tooth whitening (bleaching), both in professionally- and in self-administered products. Adverse effects have become evident. Cervical root resorption is a possible consequence of internal bleaching and is more frequently observed in teeth treated with the thermo-catalytic procedure. Tooth sensitivity is experienced in 15-78% of patients undergoing external tooth bleaching. However, clinical studies addressing other adverse effects are lacking. Direct contact with hydrogen peroxide induces genotoxic effects in bacteria and cultured epithelial cells, but the effect is reduced or totally abolished in the presence of metabolising enzymes. Several carcinogenesis studies, including the hamster cheek pouch model, indicate that hydrogen peroxide (H(2)O(2)) might possibly act as a promoter. Until further clinical research is concluded to address the question of possible carcinogenicity, it is recommended that: tooth-bleaching products using concentrated H(2)O(2) should not be used without gingival protection; that H(2)O(2) containing products should be avoided in patients with damaged or diseased soft tissues. For nightguard vital bleaching, minimal amounts of low dose H(2)O(2) (including in the form of carbamide peroxide) are preferred, thereby avoiding prolonged and concentrated exposures.

Benign esophageal stricture following aluminium phosphide poisoning

Aluminium phosphide is often implicated in accidental and suicidal poisoning in India. Ingestion of even half a fresh tablet invariably results in death, whereas exposed tablets are usually considered harmless. We report two cases of short-segment esophageal strictures that occurred following ingestion of exposed tablet of aluminium phosphide. Both cases could be successfully managed by endoscopic dilatation.

Leishmania donovani: Identification of stimulatory soluble antigenic proteins using cured human and hamster lymphocytes for their prophylactic potential against visceral leishmaniasis

Most of the studies for the identification of prophylactic antigens that elicit T cell responses were concentrated on membrane proteins of Leishmania donovani. This study was taken up to assess L. donovani soluble promastigote antigens for their ability to stimulate proliferation of peripheral blood mononuclear cells (PBMCs) from cured visceral leishmaniasis (VL) patients, endemic and non-endemic controls and lymphocytes/peritoneal macrophages of cured hamsters. The soluble protein was subjected to sequential precipitation with saturated ammonium sulphate (20%, 40%, 60% and 80%), of which largely 80% fractioned protein showed significant cellular responses in cured patients and hamsters. This fraction was further fractionated into five sub fractions by preparative SDS-PAGE and subjected to re-evaluation for their ability to induce cellular responses. Out of these, only F2 sub fraction belonging to the MW of 97.4-68 kDa stimulated remarkable lymphoproliferative and IFN-gamma responses in cured VL patients and in endemic controls. Similarly, significant lymphoproliferative responses and nitric oxide production were also noticed in cured Leishmania infected animals indicating an element of uniformity in responses between hamster and human. F2 sub fraction, when evaluated for its prophylactic efficacy with BCG against L. donovani challenge in hamster exhibited significant parasite inhibition in spleen (71.1%; p<0.001) and liver (68.2%; p<0.001) as compared to their unvaccinated counterpart. The vaccinated animals showed significant lymphoproliferative response and nitric oxide production but leishmania specific IgG level were suppressed. The results indicate the presence of immunostimulatory and protective molecules in F2 sub fraction which may further be exploited for the development of a vaccine against VL, hitherto an unrealized goal.

HLA-E and immunobiology of pregnancy

Recently, it has been suggested that non-classical antigens such as human leukocyte antigen (HLA)-G and HLA-E may interact with KIR receptors of NK cells which results into downregulation of immune response and helps in the maintenance of pregnancy. In the present study, we have investigated HLA-E polymorphism in normal fertile women and recurrent spontaneous aborters to assess the effect of HLA-E alleles on the success of pregnancy. Allele E*0101 was found to be significantly higher in patients with recurrent spontaneous abortion (chi(2) = 4.097 and P = 0.0430). Differential expression, peptide affinity, and stability of E*0101 may be one of the reasons.

Identification of Leishmania donovani antigens stimulating cellular immune responses in exposed immune individuals

Human visceral leishmaniasis (VL), also known as kala azar (KA) in India, is a systemic progressive disease caused by Leishmania donovani. In VL, Th1 responses correlate with recovery from and resistance to disease and resolution of infection results in lifelong immunity against the disease. However, recent data suggest an important role for interleukin (IL)-10 in maintaining the resistant state. We evaluated whole cell extract (WE) and 11 antigenic fractions [F1-F11, molecular weight (MW) range of 139-24.2 kDa] from L. donovani (2001 strain, a fresh field isolate from Bihar), for their ability to induce in vitro T cell proliferation and production of interferon (IFN)-gamma, interleukin (IL)-12, IL-10 and IL-4 by peripheral blood mononuclear cells (PBMCs) of exposed immune individuals (14 patients with history of VL, 10 household endemic contacts) and 20 non-endemic healthy controls. Twenty-one of 24 exposed individuals and no healthy controls showed proliferative response to WE. Whole-extract activated IFN-gamma, IL-12, IL-10 levels were higher in the exposed group than in controls; IL-4 was not detectable in any of the samples. Among 21 responders to WE, frequent proliferative responses were seen to fractions F1-F4 (MW > 64.2 kDa) and none to fractions F5-F11; fractions F1-F11 stimulated comparable levels of IFN-gamma and IL-12 while IL-10 levels were higher in response to F5-F11 compared to F1-F4. These data demonstrate the presence of immunostimulatory antigens in the high MW fractions of whole L. donovani antigen. However, these fractions do not stimulate a Th1 response and produce variable amounts of IFN-gamma and the regulatory cytokine, IL-10. Hence, these high MW immunostimulatory fractions need to be evaluated in greater depth for their possible role as protective antigens.

External cervical resorption of a primary canine

The authors describe the case of a 3-year-old boy who presented with a mobile right maxillary primary canine. Clinical examination revealed this tooth to have an abnormally large crown, which appeared to have sustained a crown-root fracture. Periodontal probing depths of 5 mm were detected around the tooth. Radiographically, there was a marked constriction at the cementoenamel junction with associated alveolar rarefaction. Both upper primary canines were subsequently removed under general anaesthetic and the right canine was subject to histopathological investigation. A diagnosis of external cervical resorption was made. A review of the literature confirmed this to be a very unusual case presentation.

Immunostimulatory cellular responses of cured Leishmania-infected patients and hamsters against the integral membrane proteins and non-membranous soluble proteins of a recent clinical isolate of Leishmania donovani

Development of an effective immunoprophylactic agent for visceral leishmaniasis (VL) has become imperative due to the increasing number of cases of drug resistance and relapse. Live and killed whole parasites as well as fractionated and recombinant preparations have been evaluated for vaccine potential. However, a successful vaccine against the disease has been elusive. Because protective immunity in human and experimental leishmaniasis is predominantly of the Th1 type, immunogens with Th1 stimulatory potential would make good vaccine candidates. In the present study, the integral membrane proteins (IMPs) and non-membranous soluble proteins (NSPs), purified from promastigotes of a recent field isolate, Leishmania donovani stain 2001, were evaluated for their ability to induce cellular responses in cured patients (n = 9), endemic controls (n = 5) of visceral leishmaniasis (VL) and treated hamsters (n = 10). IMPs and NSPs induced significant proliferative responses (SI 6.3 +/- 4.1 and 5.6 +/- 2.3, respectively; P < 0.01) and IFN-gamma production (356.3 +/- 213.4 and 294.29 +/- 107.6 pg/ml, respectively) in lymphocytes isolated from cured VL patients. Significant lymphoproliferative responses against IMPs and NSPs were also noticed in cured Leishmania animals (SI 7.2 +/- 4.7 & 6.4 +/- 4.1, respectively; P < 0.01). In addition, significant NO production in response both IMPs and NSPs was also noticed in macrophages of hamsters and different cell lines (J774A-1 and THP1). These results suggest that protective, immunostimulatory molecules are present in the IMP and NSP fractions, which may be exploited for development of a subunit vaccine for VL.

Analysis of human leukocyte antigen (HLA)-G polymorphism in normal women and in women with recurrent spontaneous abortions

Human leukocyte antigen (HLA)-G is a non-classical class I antigen. It has limited expression, but is high at the foetomaternal interface. This unique expression pattern of HLA-G suggests that it might be important for survival of the foetus during pregnancy. In the present study, 120 women with recurrent spontaneous abortions (RSA) and 120 fertile control women were genotyped for the HLA-G locus. This is the first report describing HLA-G polymorphism in normal fertile and RSA women from India. The allele HLA-G*010103 was higher in women with recurrent foetal losses. Interestingly, the HLA-G*010105 and G*010108 alleles were totally absent in normal fertile women but present in RSA women with frequencies of 1.7% and 0.4%, respectively. Allele G*010107 was absent in both the groups. The frequency of the null allele G*0105N was high (13.8%) in our population as compared to other world populations. Our data support the hypothesis that HLA-G polymorphism may contribute to recurrent foetal loss.

Mineral trioxide aggregate as a pulpotomy agent in primary molars: an in vivo study

The retention of pulpally involved deciduous tooth in a healthy state until the time of normal exfoliation remains to be one of the challenges for Pedodontists. A scientific noise has been generated about several materials some of which have been popular pulpotomy medicaments. Concerns have been raised about the toxicity and potential carcinogenicity of these materials, and alternatives have been proposed to maintain the partial pulp vitality, however to date no material has been accepted as an ideal pulpotomy agent. Mineral trioxide aggregate (MTA) is a biocompatible material which provides a biological seal. MTA has been proposed as a potential medicament for various pulpal procedures like pulp capping with reversible pulpitis, apexification, repair of root perforations, etc. Hence the present study was done to evaluate the efficacy of MTA as a pulpotomy medicament. A clinical and radiographic evaluation was done on children where MTA was used as pulpotomy medicament in primary molars for a period of 6 months and it was found to be a successful material.

Isolation of integral membrane proteins of Leishmania promastigotes and evaluation of their prophylactic potential in hamsters against experimental visceral leishmaniasis

The integral membrane proteins (IMP's) of promastigotes of two virulent strain of Leishmania (L.) donovani Dd8 and Leishmania (L.) infantum LV9 and one avirulent viscerotropic strain Leishmania tropica UR6 were extracted by phase separation technique using a non-ionic detergent "Triton X-114". This detergent is homogeneous at 0 degrees C but divides in an aqueous phase and a detergent phase at above 20 degrees C. The phase partition resulted in solubilisation of hydrophilic proteins in aqueous phase, and IMP's with an amphiphilic nature were recovered in the detergent phase. The strain wise quantitative recovery rates of IMP's were estimated. These proteins were purified by chill methanol centrifugation and used as vaccinogen, alone or in combination with adjuvant against L. donovani challenge in hamster model. Among all the combinations, hamsters immunised with IMP of L. donovani (Dd8) in combination with CFA resulted in 75% parasite inhibition in spleen (P <0.001), however, 61.14% (P <0.001) and 77.60% (P <0.001) parasitic inhibition was achieved in liver and bone marrow respectively as compared to their unvaccinated counter part. Similar combinations with UR6 and LV9 strain inhibited the parasite establishment up to 65.12% (P <0.001) and 66.87% (P <0.001), respectively on splenic site. The specific IgG level against (Dd8 strain) soluble leishmania promastigote antigen was monitored at different stages by enzyme linked immunosorbent assay (ELISA) corresponds to the level of parasitic establishment. Similar observations were made in cases of LV9 and UR6 strains. However, significant lymphoproliferative response to IMPs of Dd8 strain (SI 3.5-4.9, P <0.001) was noticed in all IMP + CFA vaccinated animals. Thus, this study will provide a lead for more manipulative trials to develop a subunit vaccine against the fatal disease.